THE PUDDLE CLIENT QUESTIONNAIRE

Kindly fill out all fields to the best of your knowledge.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

How did you hear about us? *

You have already:

Spoken to us about our swim sessions

Scheduled an appointment

CANINE INFORMATION

Dog's Name *

Breed *

Sex *

Male

Female

Date of Birth *

Weight *

CANINE HEALTH INFORMATION

Veterinarian Clinic Name *

Clinic Phone

Do you regularly vaccinate your dog? *

Yes

No

Has your dog recently suffered any injury? If so, what and when? *

Has your dog ever undergone surgery? If yes, type of surgery, and when? *

Is your dog currently on any medications? If so, what and why? *

Does your dog have any medical condition? i.e. Blind, deaf, epilepsy, incontinence, skin disorders. *

NUTRITION & EXERCISE

Describe your dog's daily exercise routine. i.e. walks, crated, play time

What do you feed you dog? i.e. brand / daily amount / treats

GENERAL INFORMATION

Your dog's swimming experience: (Check all that apply) *

What are your goals for swimming your dog with us? *

How does your dog react to being held or touched? *

Are there any behavioral issues we need to be aware of in order to ensure proper handling of your dog? *

Will you need assistance with getting your dog from the parking lot into our facility?

Yes

No

LIABILITY AGREEMENT *

I warrant that I am the owner or person responsible for the canine(s) brought to The Puddle, LLC for services, and therefore accept full liability and responsibility for damages to property, injury or death to myself, people, other animals or my own canine arising out of use of the facility and my actions, along with the actions of my canine(s), and accordingly agree to indemnify and hold harmless, The Puddle, LLC, its owners and employees for money damages and attorney fees.

I understand that The Puddle, LLC is not a licensed veterinary facility and does not provide medical procedures. I agree that I am ultimately responsible for determining whether the swim services provided by The Puddle, LLC are appropriate for my dog(s).

I understand and agree that payment is due at the time of services. I understand and agree that a 12-hour prior notice of cancellation is requested in order that my time slot can be utilized by another customer.

I understand that if my dog defecates in the pool, the swim session is immediately terminated in order for staff to begin a clean up protocol. Depending on the severity of the damage, the pool may be have to be closed. Regardless of how long the dog was in the water, the payment is non-refundable. I, the owner, may be assessed an additional fee of $50 to partially help cover the cost of cleanup.

Per my electronic signature below, I certify that I have read and understand this Agreement, and that the information set forth is true and correct. I agree to accept all the terms, conditions, and statements of this agreement, and any rules, regulations, policies and procedures of The Puddle, LLC.

Your Full Name *

Today's date * +

Thank you!

If you haven't already scheduled an appointment, we will be in touch as quickly as possible. Please note, we are closed on Sundays AND Mondays. We will also fax a short form to your veterinarian to sign, indicating that your dog will be swimming with us.

Online search	Social media (facebook)	Veterinarian
Drive by	Family or friend	Community pet event

Never been swimming	Will swim out to fetch a toy	Underwater Treadmill (Vet)
Frequently swims	Swimming pool	Lake or pond (open water)
Used to swim, but it's been awhile